Routine inspection·November 22, 2024

Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Fred Arias arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted at the facility by facility staff. LPAs met with Pamela Junge, Administrator and explained the purpose of the inspection. The facility is one-story building with 15 resident rooms,8 bathrooms, kitchen, dining room, living room, medication room, staff break room, front patio and 2-car garage. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. LPAs observed the fence on one side of the house has fallen over. LPAs determined this side of the house is accessible to residents even though it is unsafe for residents due to the collapsed fence. One deficiency is being issued. Facility has toxins, chemicals and cleaning supplies locked in the garage and a kitchen cabinet. Restrooms are stocked with soap and paper towels. Hot water measured between 105 and 120 degrees F. LPAs observed facility has emergency food and water supply as well as additional emergency supplies. LPAs reviewed six staff files and ten resident files. LPAs conducted interviews with six residents and three staff. LPAs reviewed medication. Based on medication review, LPAs determined a resident missed a medication dose, however, facility staff signed the Medication Administration Record indicating the medication was taken at the appropriate time. One deficiency is being issued. Based on record review, LPA determined the facility did not report an incident that occurred on 8/21/2024 to Licensing. One deficiency is being issued. Based on today's inspection, three deficiencies are being issued. An exit interview was conducted and a copy of this report, deficiency page and appeal rights were provided to the facility.